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Larsen MGR, Overgaard SH, Petersen SR, Møllegaard KM, Munk HL, Nexøe AB, Glerup H, Guldmann T, Pedersen N, Saboori S, Dahlerup JF, Hvas CL, Andersen KW, Jawhara M, Haagen Nielsen O, Bergenheim FO, Brodersen JB, Bygum A, Ellingsen T, Kjeldsen J, Christensen R, Andersen V. Effects of smoking on clinical treatment outcomes amongst patients with chronic inflammatory diseases initiating biologics: secondary analyses of the prospective BELIEVE cohort study. Scand J Immunol 2024; 100:e13395. [PMID: 38973149 DOI: 10.1111/sji.13395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/05/2024] [Accepted: 06/22/2024] [Indexed: 07/09/2024]
Abstract
The prevalence and disease burden of chronic inflammatory diseases (CIDs) are predicted to rise. Patients are commonly treated with biological agents, but the individual treatment responses vary, warranting further research into optimizing treatment strategies. This study aimed to compare the clinical treatment responses in patients with CIDs initiating biologic therapy based on smoking status, a notorious risk factor in CIDs. In this multicentre cohort study including 233 patients with a diagnosis of Crohn's disease, ulcerative colitis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis or psoriasis initiating biologic therapy, we compared treatment response rates after 14 to 16 weeks and secondary outcomes between smokers and non-smokers. We evaluated the contrast between groups using logistic regression models: (i) a "crude" model, only adjusted for the CID type, and (ii) an adjusted model (including sex and age). Among the 205 patients eligible for this study, 53 (26%) were smokers. The treatment response rate among smokers (n = 23 [43%]) was lower compared to the non-smoking CID population (n = 92 [61%]), corresponding to a "crude" OR of 0.51 (95% CI: [0.26;1.01]) while adjusting for sex and age resulted in consistent findings: 0.51 [0.26;1.02]. The contrast was apparently most prominent among the 38 RA patients, with significantly lower treatment response rates for smokers in both the "crude" and adjusted models (adjusted OR 0.13, [0.02;0.81]). Despite a significant risk of residual confounding, patients with CIDs (rheumatoid arthritis in particular) should be informed that smoking probably lowers the odds of responding sufficiently to biological therapy. Registration: Clinical.Trials.gov NCT03173144.
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Affiliation(s)
- Maja Graves Rosenkilde Larsen
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
- The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Silja Hvid Overgaard
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Sofie Ronja Petersen
- Department of Clinical Research, University Hospital of Southern Denmark, Odense, Denmark
| | - Karen Mai Møllegaard
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Heidi Lausten Munk
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
- Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Anders Bathum Nexøe
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- Department of Cancer and Inflammation Research, Odense University Hospital, Odense, Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Henning Glerup
- University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Tanja Guldmann
- University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Natalia Pedersen
- Department of Gastroenterology, Slagelse Hospital, Slagelse, Denmark
| | - Sanaz Saboori
- Department of Gastroenterology, Slagelse Hospital, Slagelse, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Lodberg Hvas
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Karina Winther Andersen
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Mohamad Jawhara
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Esbjerg and Grindsted Hospital, University of Southern Denmark, Esbjerg, Denmark
| | - Fredrik Olof Bergenheim
- Department of Gastroenterology, Esbjerg and Grindsted Hospital, University of Southern Denmark, Esbjerg, Denmark
| | - Jacob Broder Brodersen
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Surgery, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Torkell Ellingsen
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
- Research Unit of Medical Gastroenterology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Vibeke Andersen
- Department of Internal Medicine, Molecular Diagnostics and Clinical Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
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2
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Alizadeh M, Ali O, Cross RK. Assessing Progression of Biologic Therapies Based on Smoking Status in Patients With Crohn's Disease. Inflamm Bowel Dis 2024; 30:788-794. [PMID: 37478408 PMCID: PMC11063538 DOI: 10.1093/ibd/izad131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Active smoking is a well-established risk factor for developing Crohn's disease (CD) and negatively impacts overall disease progression. Patients who start or continue smoking after CD diagnosis are at risk for poor outcomes, higher therapeutic requirements, and have higher rates of relapse. However, it remains unclear if the exposure to smoking leads to increased sequencing through treatment therapies, especially biologics. METHODS The Study of Prospective Adult Research Cohort with IBD (SPARC IBD) registry has been collecting patient-reported outcomes data in real-time, as well as laboratory, endoscopic, and pathologic samples from 17 tertiary referral centers since 2016. In this study, we conducted a retrospective review of the SPARC clinical registry collected between December 2016 and January 2021 from 1 participating site, the University of Maryland School of Medicine's Inflammatory Bowel Disease Program. A total of 619 patients were enrolled in the SPARC IBD database. Four hundred twenty-five patients with CD were included for initial review of completeness of data; of these, 144 patients were excluded due to missing data on smoking status and/or biologic treatment, resulting in a final cohort of 281 patients. We collected and analyzed baseline demographic and clinical characteristics. The final cohort was categorized into 3 exposure groups: current, former, and never smokers. Our outcome of interest was number biologics used, categorized into 3 groups: 0, 1, or ≥2 biologics. RESULTS One hundred seventy-two never smokers, 70 former smokers, and 39 current smokers were identified. Current, former, and never smokers had no statistically significant differences in number of biologics used (ie, biologic sequencing). However, statistically significant independent risk factors for increased sequencing of biologics were identified. These risk factors included female sex, ileocolonic disease location, younger age at diagnosis, and prolonged disease duration; none of these factors remained significant in adjusted analyses. CONCLUSION To date, this is the first study assessing the association of smoking and sequencing of biologics. Although current or former smokers were not found to sequence through more biologics when compared with never smokers, smoking is a well-established risk factor for poor health outcomes, and efforts should be made to counsel patients to quit. Further, additional research must be done to stratify risk to patients based on amount of tobacco exposure.
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Affiliation(s)
- Madeline Alizadeh
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore MD 21201, USA
| | - Osman Ali
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore MD 21201, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore MD 21201, USA
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Ganesh N, Hanauer SB, Dulai PS. The importance of predicting patient responses to monoclonal antibodies for Crohn's disease. Expert Opin Biol Ther 2023; 23:941-949. [PMID: 37623370 DOI: 10.1080/14712598.2023.2252339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic immune-mediated inflammatory bowel disease that results in relapsing and remitting symptoms but progressive transmural bowel damage leading to significant morbidity. CD results from dysregulation of the immune system related to genetic and environmental factors. While the use of monoclonal antibodies targeting cytokines and adhesion molecules has been shown to improve outcomes in CD patients, their widespread use has been limited due to high costs as well as variable access. Here, we summarize the factors that have been shown to correlate with responsiveness to biologic agents for use in practice. AREAS COVERED We summarize the current literature regarding factors that have been shown to influence patient response to various biologic agents including: patient-related factors (e.g. age, gender, weight smoking history); disease-specific factors (e.g. disease duration, location/extension, behavior/phenotype, severity); genetic markers; transcription factors, and the gut microbiome. Finally, we review the utility of prediction models and present data supporting the use of recently developed decision support tools. EXPERT OPINION Clinical decision support tools developed by machine learning are currently available for the selection of biologic agents in CD patients. We expect these models to become an integral tool for clinicians in the treatment of CD in the coming years.
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Affiliation(s)
- Nisha Ganesh
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, United States of America
| | - Stephen B Hanauer
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, United States of America
| | - Parambir S Dulai
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, United States of America
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4
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Lenti MV, Scribano ML, Biancone L, Ciccocioppo R, Pugliese D, Pastorelli L, Fiorino G, Savarino E, Caprioli FA, Ardizzone S, Fantini MC, Tontini GE, Orlando A, Sampietro GM, Sturniolo GC, Monteleone G, Vecchi M, Kohn A, Daperno M, D’Incà R, Corazza GR, Di Sabatino A. Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease. Front Med (Lausanne) 2023; 10:1031998. [PMID: 37113615 PMCID: PMC10126747 DOI: 10.3389/fmed.2023.1031998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | | | - Livia Biancone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, A.O.U.I. Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Daniela Pugliese
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Gionata Fiorino
- IBD Unit, Ospedale San Camillo-Forlanini, Rome, Italy
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Flavio Andrea Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria (AOU) di Cagliari, Cagliari, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Ambrogio Orlando
- Inflammatory Bowel Disease Unit, Azienda Ospedaliera Ospedali Riuniti "Villa Sofia-Cervello" Palermo, Palermo, Italy
| | | | - Giacomo Carlo Sturniolo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Monteleone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Anna Kohn
- Gastroenterology Operative Unit, Azienda Ospedaliera San Camillo-Forlanini FR, Rome, Italy
| | - Marco Daperno
- Division of Gastroenterology, Ospedale Ordine Mauriziano di Torino, Turin, Italy
| | - Renata D’Incà
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
- *Correspondence: Antonio Di Sabatino,
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5
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Lee S, Kuenzig ME, Ricciuto A, Zhang Z, Shim HH, Panaccione R, Kaplan GG, Seow CH. Smoking May Reduce the Effectiveness of Anti-TNF Therapies to Induce Clinical Response and Remission in Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2021; 15:74-87. [PMID: 32621742 DOI: 10.1093/ecco-jcc/jjaa139] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Cigarette smoking worsens prognosis of Crohn's disease [CD]. We conducted a systematic review and meta-analysis to examine the association between smoking and induction of clinical response or remission with anti-tumour necrosis factor [TNF] therapy. METHODS MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL [June 2019] were searched for studies reporting the effect of smoking on short-term clinical response and remission to anti-TNF therapy [≤16 weeks following the first treatment] in patients with CD. Risk ratios [RR] with 95% confidence intervals [CI] were calculated using random-effects models. RESULTS Eighteen observational studies and three randomised controlled trials [RCT] were included. Current smokers and non-smokers [never or former] had similar rates of clinical response [observational studies RR: 0.96; 95% CI: 0.88, 1.05; RCTs RR: 1.09; 95% CI: 0.84, 1.41]. When restricted to studies clearly defining the smoking exposure, smokers treated with anti-TNF were less likely to achieve clinical response than non-smokers [smokers defined as having ≥5 cigarettes/day for ≥6 months RR: 0.63; 95% CI: 0.48, 0.83; lifetime never smokers vs ever smokers excluding former smokers RR: 0.81; 95% CI: 0.71, 0.93]. Current smokers were also less likely to achieve clinical remission in observational studies [RR: 0.75; 95% CI: 0.57, 0.98], though this association was not seen in RCTs [RR: 1.04; 95% CI: 0.89, 1.21]. CONCLUSIONS Smoking is significantly associated with a reduction in the ability of infliximab or adalimumab to induce short-term clinical response and remission when pooling studies where smoking status was clearly defined. When patients with CD are treated with highly effective therapy, including anti-TNF agents, concurrent smoking cessation may improve clinical outcomes.
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Affiliation(s)
- Sangmin Lee
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - M Ellen Kuenzig
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario [CHEO] Research Institute, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences [ICES], Toronto, ON, Canada
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Ziyu Zhang
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hang Hock Shim
- Department of Gastroenterology Hepatology, Singapore General Hospital, Bukit Merah, Singapore
| | - Remo Panaccione
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
| | - Cynthia H Seow
- Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Inflammatory Bowel Disease Unit, University of Calgary, Calgary, AB, Canada
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6
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Nicolaides S, Vasudevan A, Long T, van Langenberg D. The impact of tobacco smoking on treatment choice and efficacy in inflammatory bowel disease. Intest Res 2020; 19:158-170. [PMID: 33040518 PMCID: PMC8100381 DOI: 10.5217/ir.2020.00008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/22/2020] [Indexed: 12/18/2022] Open
Abstract
Smoking significantly increases the risk of developing and worsens Crohn's disease (CD), yet protects against the development and reduces the severity of ulcerative colitis. It is less clear whether smoking impacts the efficacy of therapeutics in inflammatory bowel disease (IBD). We review the literature regarding the relationship between smoking and the efficacy of medical and surgical therapy in IBD. Smoking is associated with alterations in thiopurine metabolism and may affect time to disease relapse. The outcomes of anti-tumor necrosis factor therapy in active smokers appear neutral with data lacking for newer biologics. Smoking increases the risk of postoperative recurrence in those requiring resection for CD, likely attributable to perturbations of the gut microbiota although further implications of these for disease onset/progression and treatment efficacy remain unclear. Multiple lifestyle and psychosocial confounders are likely under-recognized cofactors in the association between smoking and IBD. Despite the widely promulgated risks associated with cigarette smoking in CD, more incisive data are required to further elucidate the actual relationship between smoking and disease pathways, while accounting for the several negative cofactors prevalent in smokers which cast uncertainty on the magnitude of the direct effect of smoking on disease pathophysiology and the efficacy of therapy.
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Affiliation(s)
- Steven Nicolaides
- Department of Gastroenterology, Eastern Health, Box Hill Hospital, Box Hill, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Box Hill Hospital, Box Hill, Australia
| | - Tony Long
- Department of Gastroenterology, Eastern Health, Box Hill Hospital, Box Hill, Australia
| | - Daniel van Langenberg
- Department of Gastroenterology, Eastern Health, Box Hill Hospital, Box Hill, Australia
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7
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Atreya R, Neurath MF, Siegmund B. Personalizing Treatment in IBD: Hype or Reality in 2020? Can We Predict Response to Anti-TNF? Front Med (Lausanne) 2020; 7:517. [PMID: 32984386 PMCID: PMC7492550 DOI: 10.3389/fmed.2020.00517] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
The advent of anti-TNF agents as the first approved targeted therapy in the treatment of inflammatory bowel disease (IBD) patients has made a major impact on our existing therapeutic algorithms. They have not only been approved for induction and maintenance treatment in IBD patients, but have also enabled us to define and achieve novel therapeutic outcomes, such as combination of clinical symptom control and endoscopic remission, as well as mucosal healing. Nevertheless, approximately one third of treated patients do not respond to initiated anti-TNF therapy and these treatments are associated with sometimes severe systemic side-effects. There is therefore the currently unmet clinical need do establish predictive markers of response to identify the subgroup of IBD patients, that have a heightened probability of response. There have so far been approaches from different fields of IBD research, to descry markers that would empower us to apply TNF-inhibitors in a more rational manner. These markers encompass findings from disease-related and clinical factors, pharmacokinetics, biochemical markers, blood and stool derived parameters, pharmacogenomics, microbial species, metabolic compounds, and mucosal factors. Furthermore, changes in the intestinal immune cell composition in response to therapeutic pressure of anti-TNF treatment have recently been implicated in the process of molecular resistance to these drugs. Insights into factors that determine resistance to anti-TNF therapy give reasonable hope, that a more targeted approach can then be utilized in these non-responders. Here, IL-23 could be identified as one of the key factors determining resistance to TNF-inhibitors. Growing insights into the molecular mechanism of action of TNF-inhibitors might also enable us to derive critical molecular markers that not only mediate the clinical effects of anti-TNF therapy, but which level of expression might also correlate with its therapeutic efficacy. In this narrative review, we present an overview of currently identified possible predictive markers for successful anti-TNF therapy and discuss identified molecular pathways that drive resistance to these substances. We will also point out the necessity and difficulty of developing and validating a diagnostic marker concerning clinically relevant outcome parameters, before they can finally enter daily clinical practice and enable a more personalized therapeutic approach.
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Affiliation(s)
- Raja Atreya
- Department of Medicine, Medical Clinic 1, University Hospital Erlangen, University of Erlangen-Nürnberg Erlangen, Erlangen, Germany.,Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany.,The Transregio 241 IBDome Consortium, Erlangen, Germany
| | - Markus F Neurath
- Department of Medicine, Medical Clinic 1, University Hospital Erlangen, University of Erlangen-Nürnberg Erlangen, Erlangen, Germany.,Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany
| | - Britta Siegmund
- The Transregio 241 IBDome Consortium, Berlin, Germany.,Medizinische Klinik m. S. Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
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8
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Gisbert JP, Chaparro M. Predictors of Primary Response to Biologic Treatment [Anti-TNF, Vedolizumab, and Ustekinumab] in Patients With Inflammatory Bowel Disease: From Basic Science to Clinical Practice. J Crohns Colitis 2020; 14:694-709. [PMID: 31777929 DOI: 10.1093/ecco-jcc/jjz195] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Inflammatory bowel diseases [IBD]-ulcerative colitis and Crohn's disease-are commonly treated with biologic drugs. However, only approximately two-thirds of patients have an initial response to these therapies. Personalised medicine has the potential to optimise efficacy, decrease the risk of adverse drug events, and reduce costs by establishing the most suitable therapy for a selected patient. AIM The present study reviews the potential predictors of short-term primary response to biologic treatment, including not only anti-tumour necrosis factor [TNF] agents [such as infliximab, adalimumab, certolizumab, and golimumab] but also vedolizumab and ustekinumab. METHODS We performed a systematic bibliographical search to identify studies investigating predictive factors of response to biologic therapy. RESULTS For anti-TNF agents, most of the evaluated factors have not demonstrated usefulness, and many others are still controversial. Thus, only a few factors may have a potential role in the prediction of the response, including disease behaviour/phenotype, disease severity, C-reactive protein, albumin, cytokine expression in serum, previous anti-TNF therapy, some proteomic markers, and some colorectal mucosa markers. For vedolizumab, the availability of useful predictive markers seems to be even lower, with only some factors showing a limited value, such as the expression of α4β7 integrin in blood, the faecal microbiota, some proteomic markers, and some colorectal mucosa markers. Finally, in the case of ustekinumab, no predictive factor has been reported yet to be helpful in clinical practice. CONCLUSION In summary, currently no single marker fulfils all criteria for being an appropriate prognostic indicator of response to any biologic treatment in IBD.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
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9
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Smoking Status at Diagnosis and Subsequent Smoking Cessation: Associations With Corticosteroid Use and Intestinal Resection in Crohn's Disease. Am J Gastroenterol 2018; 113:1689-1700. [PMID: 30323269 DOI: 10.1038/s41395-018-0273-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of smoking at diagnosis and subsequent smoking cessation on clinical outcomes in Crohn's disease (CD) has not been evaluated in a population-based cohort. METHODS Using a nationally representative clinical research database, we identified incident cases of CD between 2005 and 2014. We compared the following outcomes: overall corticosteroid (CS) use; flares requiring CS; CS dependency and intestinal surgery between smokers and non-smokers at time of CD diagnosis. Differences in these outcomes were also compared between persistent smokers and smokers who quit within 2 years of diagnosis. RESULTS We identified 3553 patients with a new CD diagnosis over the study period of whom 1121 (32%) were smokers. Smokers at CD diagnosis had significantly higher CS-use (56 versus 47%, p < 0.0001), proportionally more CS flares (>1 CS flare/year: 9 versus 6%, p < 0.0001), and higher CS dependency (27 versus 21%, p < 0.0001) than non-smokers. Regression analysis identified smoking at diagnosis to be associated with a higher risk of intestinal surgery (HR 1.64, 95% CI 1.16-2.52). There was a significantly higher proportion of 'quitters' who remained steroid-free through follow-up in comparison to 'persistent smokers' (45.4 versus 37.5%, respectively, p = 0.02). 'Quitters' also had lower rates of CS dependency compared to 'persistent smokers' (24 versus 33%, p = 0.008). CONCLUSIONS Smokers at CD diagnosis have higher CS-use, CS dependency and higher risk of intestinal surgery. Quitting smoking appears to have beneficial effects on disease related outcomes, including reducing CS dependency highlighting the importance of offering early smoking cessation support.
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Kopylov U, Seidman E. Predicting durable response or resistance to antitumor necrosis factor therapy in inflammatory bowel disease. Therap Adv Gastroenterol 2016; 9:513-26. [PMID: 27366220 PMCID: PMC4913332 DOI: 10.1177/1756283x16638833] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Monoclonal antibodies to tumor necrosis factor (TNF) have become a mainstay of the therapeutic armamentarium in inflammatory bowel disease (IBD) over the last 15 years. Although highly effective, primary and secondary nonresponse are common and associated with poor clinical outcomes and significant costs. Multiple clinical, genetic and immunopharmacological factors may impact the response to anti-TNFs. Early stratification of IBD patients by the expected risk of therapeutic failure during the induction and maintenance phases of treatment may allow for treatment optimization and potentially optimal short- and long-term outcomes. The aim of this review is to summarize the current data concerning the potential predictors of therapeutic success and failure of anti-TNFs in IBD.
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Affiliation(s)
- Uri Kopylov
- Division of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ernest Seidman
- Professor of Medicine and Pediatrics McGill University, Director, IBD Center of Excellence at McGill, Bruce Kaufman Endowed Chair in IBD at McGill, Canada Research Chair in Immune Mediated Gastrointestinal Disorders, Digestive Lab Research Institute of the McGill University Health Centre, 1650 Cedar Avenue C10.145, Montreal, QC H3G 1A4, Canada
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Abstract
OBJECTIVES Patients with Crohn's disease (CD) who smoke are at a higher risk of flaring and requiring surgery. Cost-effectiveness studies of funding smoking cessation programs are lacking. Thus, we performed a cost-utility analysis of funding smoking cessation programs for CD. METHODS A cost-utility analysis was performed comparing five smoking cessation strategies: No Program, Counseling, Nicotine Replacement Therapy (NRT), NRT+Counseling, and Varenicline. The time horizon for the Markov model was 5 years. The health states included medical remission (azathioprine or antitumor necrosis factor (anti-TNF), dose escalation of an anti-TNF, second anti-TNF, surgery, and death. Probabilities were taken from peer-reviewed literature, and costs (CAN$) for surgery, medications, and smoking cessation programs were estimated locally. The primary outcome was the cost per quality-adjusted life year (QALY) gained associated with each smoking cessation strategy. Threshold, three-way sensitivity, probabilistic sensitivity analysis (PSA), and budget impact analysis (BIA) were carried out. RESULTS All strategies dominated No Program. Strategies from most to least cost effective were as follows: Varenicline (cost: $55,614, QALY: 3.70), NRT+Counseling (cost: $58,878, QALY: 3.69), NRT (cost: $59,540, QALY: 3.69), Counseling (cost: $61,029, QALY: 3.68), and No Program (cost: $63,601, QALY: 3.67). Three-way sensitivity analysis demonstrated that No Program was only more cost effective when every strategy's cost exceeded approximately 10 times their estimated costs. The PSA showed that No Program was the most cost-effective <1% of the time. The BIA showed that any strategy saved the health-care system money over No Program. CONCLUSIONS Health-care systems should consider funding smoking cessation programs for CD, as they improve health outcomes and reduce costs.
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Inamdar S, Volfson A, Rosen L, Sunday S, Katz S, Sultan K. Smoking and early infliximab response in Crohn’s disease: a meta-analysis. J Crohns Colitis 2015; 9:140-6. [PMID: 25518060 DOI: 10.1093/ecco-jcc/jju018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infliximab is used to treat moderate to severe Crohn’s disease (CD), but its efficacy varies. Although cigarette smoking worsens CD, its impact on the infliximab response is unknown. We conducted a systematic review and meta-analysis of clinical trials to determine the effect of smoking on the induction response to infliximab. METHODS A systematic search was performed of MEDLINE, EMBASE, CINAHL, the Cochrane central register of controlled trials, the Cochrane IBD Group Specialized Trials Register for publications, and abstracts from major conferences from January 1996 to December 2010. Random effects meta-analysis using the Mantel–Haenszel method was conducted. Heterogeneity across studies was assessed using the Q statistic, the I2 statistic, and τ2. RESULTS We identified 12 articles; four were excluded due to use of non-validated scoring systems.The remaining eight included a total of 1658 patients, with 649 active smokers. Luminal response was assessed by the Crohn’s Disease Activity Index in four studies (three of which included fistula response) and the Harvey–Bradshaw index in two (both including fistula response), and two studies examined only the fistula response. The relative risk for response to infliximab among smokers was 0.99 (95% CI 0.88–1.11) (τ2 = 0.0143). Analyses of the five studies examining both inflammatory and fistulizing CD were similar to the analysis of all eight studies. The pooled relative risk was 0.92 (95% CI 0.80–1.06) (τ2 = 0.0154). CONCLUSION Though smoking worsens CD, this meta-analysis does not show a negative effect of smoking on initial response to infliximab. This must be viewed in the proper context, as long-term maintenance of response may yet be influenced by smoking status.
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Song IS, Sohn HS, Kim H, Lim E, Kwon M, Ha JH, Kwon JW. Impact of smoking on the effectiveness of TNF-α inhibitors in patients with rheumatoid arthritis or Crohn's disease. Transl Clin Pharmacol 2014. [DOI: 10.12793/tcp.2014.22.2.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Im-Sook Song
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 700-721, South Korea
| | - Hyun Soon Sohn
- Graduate School of Clinical Pharmacy, CHA University, Gyeonggi-do 463-836, South Korea
| | - Hyunah Kim
- College of Pharmacy, Sookmyung University, Seoul 140-742, South Korea
| | - Eunjeong Lim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 700-721, South Korea
| | - Mihwa Kwon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 700-721, South Korea
| | - Ji-Hye Ha
- Clinical Research Division, National Institute of Food and Drug Safety Evaluation (NIFDS) Chungcheongbuk-do 363-700, South Korea
| | - Jin-Won Kwon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 700-721, South Korea
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Maharshak N, Plevy SE. A Crohn's disease patient who does not respond to infliximab: what is next? Clin Gastroenterol Hepatol 2011; 9:1033-8. [PMID: 21699811 DOI: 10.1016/j.cgh.2011.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 04/28/2011] [Accepted: 05/18/2011] [Indexed: 02/07/2023]
Affiliation(s)
- Nitsan Maharshak
- Department of Medicine, Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Sprakes MB, Hamlin PJ, Warren L, Greer D, Ford AC. Adalimumab as second line anti-tumour necrosis factor alpha therapy for Crohn's disease: A single centre experience. J Crohns Colitis 2011; 5:324-31. [PMID: 21683302 DOI: 10.1016/j.crohns.2011.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 01/20/2011] [Accepted: 02/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Non-response, loss of response, or intolerance to anti-tumour necrosis factor alpha (anti-TNFα) therapy is well recognised in Crohn's disease (CD) patients. Data concerning outcomes following the use of a second anti-TNFα therapy, particularly in patients who do not respond to a first anti-TNFα agent, are still emerging. The aim of this study was to assess response and tolerability to adalimumab following infliximab failure in a single centre cohort of CD patients. METHODS Data were collected prospectively on 44 patients who received adalimumab therapy following infliximab failure. Initial response to adalimumab therapy at 6weeks following induction was defined using a two point decrease in the Harvey-Bradshaw Index, with remission at this point defined using a Harvey Bradshaw index≤4. Sustained clinical benefit at the last point of follow up was determined using a physician's global assessment. Corticosteroid-free sustained clinical benefit was also assessed at this point. RESULTS Thirty-four (77%) patients had initial response to adalimumab therapy, with 28 (64%) having sustained clinical benefit. Corticosteroid-free sustained clinical benefit was achieved in nine (53%) of 17 patients requiring steroids at commencement of adalimumab. Four (44%) of the 9 patients who were primary non-responders to infliximab responded to adalimumab. The majority of CD patients who failed adalimumab therapy required surgery. CONCLUSIONS Second-line anti-TNFα therapy with adalimumab is effective at both inducing remission and maintaining response in CD patients who have failed infliximab, regardless of the reason for infliximab failure.
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Affiliation(s)
- Michael B Sprakes
- Leeds Gastroenterology Institute, Leeds General Infirmary, Leeds, LS1 3EX, United Kingdom.
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González-Lama Y, Vera MI, Calvo M, Abreu L. [Markers of the course of inflammatory bowel disease treated with immunomodulators or biological agents]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:449-60. [PMID: 20122758 DOI: 10.1016/j.gastrohep.2009.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 11/01/2009] [Indexed: 11/19/2022]
Abstract
Immunosuppressive or biological treatment in patients with inflammatory bowel disease can modify the natural history of their disease, although these treatments are not universally effective and can have severe adverse effects. Attempts have been made to identify predictive factors of response to the various therapeutic options in order to aid the choice of the most appropriate therapeutic alternative in each patient. The possibility of modifying any one of these predictive factors would be of great interest since it would provide the opportunity to alter the course of the disease. Epidemiological, biological, clinical, endoscopic, radiological, genetic and even proteomic markers have been studied, in addition to others related to the disease itself or to specific treatments. The present article briefly discusses the real use of each of these markers and the evidence supporting their utility.
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Affiliation(s)
- Yago González-Lama
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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